2018 Resident Life and Health Forms. We are SJA.

Transcription

1 2018 Resident Life and Health Forms We are SJA.

2 QUESTIONS? CONTACT DUE JULY 1 Included on the following pages are important forms from the Campus Life, Health, and Business Offices that need to be returned by JULY 1, Before returning these forms, please take a few moments and be sure you have signed and dated all the appropriate areas. WE HAVE PREPARED THESE FORMS AS PDFS FOR YOUR CONVENIENCE. SIMPLY FILL OUT THE INFORMATION AND THE FILES BACK TO US! If at any point during this process you have questions please call the appropriate department (Campus Life Office, Business Services Office, Nurse s Office). We will be happy to answer any questions you might have. If you wish to fax the required forms, the Admission Office fax number is to forms@stjacademy.org or upload to your SNAP Health Portal page. Login information will be sent directly to parents and consultants.

3 IMPORTANT NUMBERS Admission Office Jan Monteith EXECUTIVE ASSISTANT Admission Office fax: Campus Life Office Buffie Hegarty ADMINISTRATIVE ASSISTANT Campus Life Office Fax: Business Services Office Marci McGinn STUDENT ACCOUNTS COORDINATOR Business Office Fax Nurse s Office Crystal Prevost ADMINISTRATIVE ASSISTANT cprevost@stjacademy.org Nurse s Office Fax

4 4 R E S I D E N T L I F E F O R M S Main Street, St. Johnsbury, Vermont Telephone: (802) , Fax: (802) STUDENT INFORMATION PLEASE PRINT FULL NAME BELOW (REQUIRED FOR ALL FORMS) STUDENT LAST NAME STUDENT MIDDLE NAME STUDENT FIRST NAME STUDENT NICKNAME OF BIRTH: YEAR MONTH DAY GENDER: MALE FEMALE STUDENT ADDRESS STUDENT CELL PHONE WITH AREA CODE COUNTRY NATIONALITY CITIZENSHIP Student Guardian Information With whom does the student reside: Mother Father Guardian MOTHER/GUARDIAN LAST NAME MOTHER/GUARDIAN FIRST NAME MOTHER/GUARDIAN MAILING ADDRESS: STREET STREET LINE 2 CITY STATE COUNTRY ZIP CODE MOTHER/GUARDIAN HOME PHONE WITH AREA CODE MOTHER/GUARDIAN ADDRESS MOTHER/GUARDIAN FAX NUMBER WITH AREA CODE MOTHER/GUARDIAN WORK PHONE WITH AREA CODE MOTHER/GUARDIAN CELL PHONE WITH AREA CODE FATHER/GUARDIAN LAST NAME FATHER/GUARDIAN FIRST NAME FATHER/GUARDIAN MAILING ADDRESS: STREET STREET LINE 2 CITY STATE COUNTRY ZIP CODE FATHER/GUARDIAN HOME PHONE WITH AREA CODE FATHER/GUARDIAN ADDRESS FATHER/GUARDIAN FAX NUMBER WITH AREA CODE FATHER/GUARDIAN WORK PHONE WITH AREA CODE FATHER/GUARDIAN CELL PHONE WITH AREA CODE

5 5 R E S I D E N T L I F E F O R M S STUDENT LAST NAME STUDENT FIRST NAME Consultant Information (if applicable) CONSULTANT COMPANY NAME CONSULTANT LAST NAME CONSULTANT FIRST NAME CONSULTANT MAILING ADDRESS: STREET STREET LINE 2 CITY STATE COUNTRY ZIP CODE CONSULTANT WORK PHONE WITH AREA CODE CONSULTANT FAX NUMBER WITH AREA CODE Emergency Contact CONSULTANT CELL PHONE WITH AREA CODE CONSULTANT ADDRESS In case of emergency, please give the name and phone number of the person to be contacted. EMERGENCY CONTACT LAST NAME EMERGENCY CONTACT FIRST NAME RELATIONSHIP TO STUDENT EMERGENCY CONTACT HOME PHONE WITH AREA CODE EMERGENCY CONTACT FAX NUMBER WITH AREA CODE EMERGENCY CONTACT WORK PHONE WITH AREA CODE EMERGENCY CONTACT ADDRESS PARENTAL PERMISSION FORM Because of the responsibility and liability involved, it is necessary for the Academy to forbid resident students to ride in cars without the written permission of the parent. The permission, if granted by the parent, must be on file in the dormitory master s office before the student will be permitted to use private transportation while under the jurisdiction of the school. This form grants permission to ride in any vehicle not owned by the Academy. The school does not encourage such permission. Transportation to Academy functions will, of course, be provided. St. Johnsbury Academy reserves the right to withhold the privilege provided by the above permission if the situation warrants. My child has, does not have, my permission to ride in private cars with an adult My child has, does not have, my permission to ride in private cars with a student driver X PARENT/GUARDIAN SIGNATURE

6 6 R E S I D E N T L I F E F O R M S STUDENT LAST NAME STUDENT FIRST NAME PERMISSION TO PHOTOGRAPH St. Johnsbury Academy uses photographs of students in their marketing materials. PLEASE INDICATE WHETHER OR NOT YOU GRANT PERMISSION FOR USE OF YOUR CHILD'S PHOTO. Yes, I give my permission for St. Johnsbury Academy to use my child s photo for school-related activities. No, I do not give my permission for St. Johnsbury Academy to use my child s photo for school-related activities. x PARENT/GUARDIAN SIGNATURE STUDENT ACTIVITY FORM All resident students are required to participate in extracurricular or intramural programs, unless there is a physical handicap. We encourage students to become active in sports or other physical activities. I GRANT PERMISSION FOR MY CHILD TO PARTICIPATE IN ACADEMY ACTIVITIES WITH THE FOLLOWING EXCEPTIONS: x PARENT/GUARDIAN SIGNATURE COMMUNICATION St. Johnsbury Academy provides consistent communication to parents regarding the daily activities of life on campus via the Academy s website We utilize as the primary communications vehicle to send announcements, school closing, travel plans, etc. A valid address is vital to our efforts to communicate effectively. Please provide the primary address(es) that the Academy should use for these important communications: STUDENT NAME PRIMARY ADDRESS SECONDARY ADDRESS IF YOUR CONTACT INFORMATION CHANGES, PLEASE CHANGES TO JAN MONTEITH AT JMONTEITH@STJACADEMY.ORG

7 7 R E S I D E N T L I F E F O R M S Main Street, St. Johnsbury, Vermont Telephone: (802) , Fax: (802) STUDENT LAST NAME PERMISSION FOR MEDICAL TREATMENT / RELEASE OF MEDICAL INFORMATION (To be completed every year) In rare instances, a surgical emergency arises in which written consent by the parent or guardian is legally required but the proper person cannot be located. In this event, and in order to avoid delay which might jeopardize the life or recovery of a student, we request the following information from the parents or guardian, with the understanding that every effort will be made to contact them in an emergency. STUDENT FIRST NAME Student s Social Security Number: I authorize the School Nurse, or other health care providers considered appropriate by them, to carry out accepted procedures for diagnosis, immunization, medical and minor surgical treatment, or counseling for my (son, daughter, ward). I authorize the School Nurse or other physicians or surgeons considered appropriate by him/her to give necessary anesthesia and perform emergency surgical operations on my (son, daughter, ward). I agree to notify St. Johnsbury Academy of any conditions arising when my (son, daughter, ward) is not at school. I hereby authorize St. Johnsbury Academy to release information concerning my child to appropriate health care providers. I authorize health care providers to release information to the school. I hereby authorize payment directly to the health care provider of the hospital insurance benefits otherwise payable to me but not to exceed the balance due of the hospital s regular charges for this period of hospitalization. I understand I am financially responsible to the health care provider for charges not covered by this authorization and any applicable rates and terms. Our health care professionals, counselors, advisors, and administrators strive to respect the privacy of our students; however, there are times when information may need to be shared with parents, select faculty, and school officials. Therefore, parents and students consent, as a condition of enrollment, that otherwise confidential health care and counseling information may be disclosed on a need to know basis to the extent necessary to protect the health, safety, and welfare of the student and community. x PARENT/GUARDIAN SIGNATURE

8 8 R E S I D E N T L I F E F O R M S STUDENT LAST NAME STUDENT FIRST NAME HEALTH INSURANCE INFORMATION (To be completed every year) Every student MUST HAVE health insurance Please choose one of the following: I have chosen for my international student to participate in St. Johnsbury Academy s Health Insurance plan (Recommended). Do not fill out this page. Please go to the next page. I have declined St. Johnsbury Academy s Health Insurance plan and have my own coverage. Please complete the following information and include a copy of both sides of your insurance card and prescription drug card. POLICY HOLDER S NAME POLICY HOLDER'S SOCIAL SECURITY NUMBER POLICY NUMBER GROUP NUMBER RELATIONSHIP TO POLICY SUBSCRIBER INSURANCE COMPANY NAME WHERE TO SEND CLAIM FORMS MAILING ADDRESS: STREET STREET LINE 2 CITY STATE COUNTRY ZIP CODE TELEPHONE NUMBER WITH AREA CODE PERSON RESPONSIBLE FOR HEALTH CARE BILLS LAST NAME FIRST NAME HOME PHONE WITH AREA CODE BUSINESS PHONE WITH AREA CODE FAX NUMBER WITH AREA CODE ADDRESS MAILING ADDRESS: STREET STREET LINE 2 CITY STATE COUNTRY ZIP CODE

9 9 R E S I D E N T L I F E F O R M S STUDENT LAST NAME STUDENT FIRST NAME To be completed by Parents every year The following over the counter medications will be administered to your child on an as needed basis. Please indicate below any objections or allergies we may need to be aware of. MEDICATION Tylenol Ibuprofen Sudafed (cold medicine) Antacid Benadryl Cough suppressants Anti-Diarrhea Laxative Other Medication prescribed by the Physician OBJECTIONS/ALLERGIES CONSENT TO DRUG TEST / RELEASE OF MEDICAL INFORMATION I/we understand that our student may receive disciplinary action, including suspension and/or expulsion from St. Johnsbury Academy, for violating the Academy's Substance abuse policy. Therefore, I/we hereby give consent for said student s urine and/or blood to be obtained for drug/alcohol testing. I also give permission for Northeastern Vermont Regional Hospital to release aforementioned test results to the Headmaster of St. Johnsbury Academy and shall hold said hospital and healthcare providers at said hospital harmless and release them from any liability in performing said test and release of the results. x STUDENT SIGNATURE PRINTED NAME OF STUDENT x PARENT/GUARDIAN SIGNATURE PRINTED NAME OF PARENT/GUARDIAN

10 10 H E A L T H F O R M S STUDENT LAST NAME STUDENT FIRST NAME MEDICAL HISTORY (To be completed by Parents every year) Does your child have or ever had? YES NO Comment ADHD /Learning Disability Alcohol/Substance use Anemia/Blood disorder Asthma/Lung problems Back problems Cancer/Tumor Chest pain/shortness of breath COUNSELING/PSYCHOTHERAPY Doctor s Name Phone number Dental problems Depression Diabetes Ear, Nose, Throat problems Eye problems Fainting/Loss of consciousness Fractures/Sprain/Dislocation Headaches Head injury/concussion Heart Disease High Blood Pressure Intestinal/Digestive problems Kidney disease/bladder Measles Mononucleosis Mumps Pneumonia Rheumatic Fever Seizures Significant Anxiety Sinusitis Skin problems Special Diet TB Thyroid/Hormone problems Tobacco Use Weight change/anorexia ALLERGIES: Reaction: Date of last Dental exam / /

11 11 H E A L T H F O R M S REPORT OF HEALTH EVALUATION (To be completed by a Physician every year) Year of graduation TO THE EXAMINING PHYSICIAN: PLEASE REVIEW THE STUDENT S HISTORY AND COMPLETE THIS PHYSICAL FORM. PLEASE COMMENT ON ALL YES ANSWERS. SEX: F M STUDENT LAST NAME STUDENT FIRST NAME OF BIRTH YEAR OF GRADUATION Blood pressure Weight Height Tuberculin Skin Test: ALL STUDENTS from Latin America, the Caribbean, Africa, Asia, Eastern Europe and Russia Date Type BCG Date Result: Negative Positive Induration mm Has the student had Chest x-ray? result Please include copy of chest x-ray report. Date Is there sign or symptom of active tuberculosis? Are there any chronic conditions that require treatment or periodic evaluation? Allergies ARE THERE ABNORMALITIES OF THE FOLLOWING SYSTEMS? DESCRIBE FULLY. PLEASE USE AN ADDITIONAL SHEET, IF NECESSARY. Yes No Yes No Head, ears, nose, throat Genitourinary Respiratory Musculoskeletal Cardiovascular Metabolic/Endocrine Gastrointestinal Neuropsychiatric Hernia Skin Eyes Any other condition ARE THERE ANY RESTRICTIONS TO PHYSICAL ACTIVITY OR PARTICIPATION IN A COMPETITIVE ATHLETIC PROGRAM? No Yes (If Yes, please list) ANY KNOWN INJURY OF OR CONDITION OF: Back Date Knee Date Shoulder Date Head Date Other injury Date Treatment Treatment Treatment Treatment Treatment x SIGNATURE OF DOCTOR/PHYSICIAN

12 12 H E A L T H F O R M S STUDENT LAST NAME STUDENT FIRST NAME REPORT OF HEALTH EVALUATION continued LIST ALL MEDICATIONS AND THEIR DOSAGES (INCLUDING OVER-THE-COUNTER AND SUPPLEMENTS) Medication Dosage Instructions ALL MEDICATIONS ARE ADMINISTERED BY THE HEALTH OFFICE. PLEASE DELIVER THEM TO THE OFFICE UPON YOUR ARRIVAL TO CAMPUS PRESCRIPTION REFILLS SHOULD BE SENT TO GAUTHIER'S PHARMACY ( ). I confirm do not confirm that the above named Student is capable of self-administration of his/her medication when traveling from home to school or to school-related destination or when traveling to his/her destination during school vacations and when signing off from campus on weekends. Towards that end, I further confirm that the Student has been advised of the possible side-effects of all prescription medications, including any possible interactions with the above-listed over-the-counter medications and supplements, and has been informed of when and how to access emergency services. EXAMINING PHYSICIAN SIGNATURE EXAMINING PHYSICIAN PRINT MAILING ADDRESS: STREET STREET LINE 2 CITY STATE COUNTRY ZIP CODE BUSINESS PHONE WITH AREA CODE FAX NUMBER WITH AREA CODE ADDRESS x SIGNATURE OF DOCTOR/PHYSICIAN

13 13 H E A L T H F O R M S STUDENT LAST NAME STUDENT FIRST NAME IMMUNIZATIONS (To be completed the first year at St. Johnsbury Academy) This information is required and very important. Prior to your student entering St. Johnsbury Academy, he/she must have completed the Vermont state required immunizations listed below. All students who do not have proof of the requires immunizations will be immunized locally at the family's expense, which could be as much as $500, depending on the immunization required. DIPHTHERIA/PERTUSSIS/TETANUS Date of dose 1 / / Date of dose 2 / / Date of dose 3 / / Date of dose 4 / / Date of dose 5 / / TDAP / / TDAP must have regardless of last TD date POLIO Date of dose 1 / / OPV IPV Date of dose 2 / / OPV IPV Date of dose 3 / / OPV IPV Date of dose 4 / / OPV IPV HPV VACCINE: (HIGHLY RECOMMENDED) Has my permission to receive the HPV vaccine / / Date of dose 2 / / Date of dose 3 / / MEASLES/MUMPS/RUBELLA (MMR) Date of dose 1 / / Date of dose 2 / / TUBERCULIN TEST - Students from Latin America, Caribbean, Africa, Asia, Eastern Europe, Russia TB skin test Date: / / Results mm in duration (positive over 10mm in duration) If Positive skin test: Date of chest x-ray: / / Results: Previous BCG Date: / / HEPATITIS B Date of dose 1 / / Date of dose 2 / / Date of dose 3 / / MENINGOCOCCAL VACCINE (REQUIRED BY VT LAW) Check the appropriate box: Menomune Menactra Date of dose 1 / / VARICELLA (REQUIRED IF NO HISTORY OF DISEASE) Date of dose 1 / / Date of dose 2 / / History of disease Date: / / Permission for Influenza Vaccine: HIGHLY RECOMMENDED Please check one: Has my permission to receive the influenza vaccine Does NOT have my permission to receive the influenza vaccine By Law, students may not be enrolled in school without this information I AUTHORIZE ST. JOHNSBURY ACADEMY TO COMPLETE THE NECESSARY SERIES OF IMMUNIZATIONS. x PARENT/GUARDIAN SIGNATURE

14 14 H E A L T H F O R M S REQUIRED FOR STUDENTS TAKING PRESCRIPTIONS OR SUPPLEMENTS ONLY STUDENT S LAST NAME STUDENT S FIRST NAME PARENTAL CONSENT AND AGREEMENT (To be completed every year) I, acknowledge and agree that all prescriptions and over-the-counter medications/supplements must be given to the St. Johnsbury Academy Director of Health and Wellness, together with written orders from a physician. (The physician s orders must detail the name of the drug, dosage, time interval the medication is to be taken, diagnosis, and reason for giving.) My completion of this form constitutes my request for The Academy to comply with the physician s orders. I hereby assure St. Johnsbury Academy that my child has suffered no previous ill effects from the use of the listed medications. My completion of this form constitutes my request and consent to have SJA store and administer, and allow my child to self administer, the listed prescription and nonprescription medications and supplements. I specifically consent to St. Johnsbury Academy: (1) to store and administer the listed medications, over-the-counter medications and supplements to my child, (2) to disclose these medications whenever it seeks medical services on my child s behalf, and (3) to have my son/daughter selfadminister the listed medications as indicated by his/her physician s attached orders and the information listed in this form. I give further permission to St. Johnsbury Academy for my son/daughter to have in his/her possession their prescribed medications when traveling from home to school or to school-related destination or when traveling to his/her destination during school vacations and when signing off from campus on weekends. I agree that my child will be given only the amount of prescription medications (except for the listed emergency medications) needed for the time he/she will be away from school. I acknowledge and agree that medication must be brought to school in a container labeled by the pharmacy or physician and stored by the St. Johnsbury Academy Director of Health Services, or his or her designee, in a secure storage place. I acknowledge and agree that I have reviewed the possible side effects of the listed non-prescription medications and supplements (listed on the medication or supplement s container) with my child. I acknowledge and agree that I have disclosed all information concerning any life threatening allergies or asthma that my child may have to the St. Johnsbury Academy Director of Health and Wellness and hereby agree to supplement that information as needed in order to ensure my child s safety and well being. Students with life threatening allergies or with asthma, and whose parents or guardians have completed the consent form below, shall be permitted to possess and self-administer emergency medication at school, on school grounds, at school-sponsored activities, on school-provided transportation, and during school-related programs. I further agree to provide St. Johnsbury Academy a newly completed form (accessed from the School s website) whenever my child s prescription and non-prescription medications are changed. I agree to telephone the St. Johnsbury Academy Director of Health Services with any specific new instructions related to medications and to or fax the newly completed form promptly to: Sarah Garey, RN, NCSN, CADC Director of Health Services fax sgarey@stjacademy.org I further acknowledge and agree that if I have any concerns or questions about the administration of my child s medication or supplements, then I will contact without delay the St. Johnsbury Academy s Director of Health Services. I hereby release the school, its employees and agents, including volunteers, from liability as a result of any injury arising from my child s self-administration of the abovelisted prescription, non-prescription medications, or supplements. x SIGNATURE OF PARENT/GUARDIAN

15 15 H E A L T H F O R M S REQUIRED FOR STUDENTS TAKING EMERGENCY MEDICATIONS ONLY STUDENT S LAST NAME STUDENT S FIRST NAME PARENTAL AUTHORIZATION FORM - EMERGENCY MEDICATION (To be completed every year) As the parent (or guardian) of, I hereby authorize my child to possess and self administer emergency medication at school, on school grounds, at school sponsored activities, on school provided transportation, and during school-related programs. As documented by the attached physician s statement, my child has (name the specific life-threatening allergies or asthma applicable to this authorization), and is capable of, and has been instructed by the physician in, properly self-administering the emergency medication named by the physician. As further documented by the attached physician s statement, my child has been advised of possible side-effects of the medication and has been informed of when and how to access emergency services. The attached plan of action, developed specifically for the 2017/2018 school year, in consultation with the SJA Director of Health Services, is based on the documentation provided by the physician s statement and includes the name of each emergency medication, the dosage, and the times and circumstances under which the medication is to be taken. The plan of action also indicates that the medication is solely for the use of my child, and includes the names of individuals who will be given copies of the plan. I understand that one of the requirements of the plan is that my child will notify a school employee or agent after self-administering emergency medication. I hereby release the school, its employees and agents, including volunteers, from liability as a result of any injury arising from my child s self-administration of emergency medication. x SIGNATURE OF PARENT/GUARDIAN

16 16 R E S I D E N T L I F E F O R M S STUDENT LAST NAME STUDENT FIRST NAME STUDENT NICK NAME POCKET MONEY/ALLOWANCE ACCOUNTS (OPTIONAL) As a convenience to families, parents may choose to deposit funds into a pocket money/allowance account held for safekeeping by the Business Office. Funds are distributed to students either as weekly pocket money or on an as needed basis for student expenses such as weekend activities, shopping, and entertainment. To open a Pocket Money account you may send funds via bank wire, credit card, electronic check (ACH) or by mailing a check. Credit card deposits may be made online at by choosing Online Payments from the Quicklinks menu, selecting Make an Online Payment, then Make a Payment, and following online instructions. Electronic check (ACH) payments may be made online by U.S. families at by choosing Online Payments from the Quicklinks menu, selecting Make an Online Payment, then Make a Payment, and following online instructions. The ACH (electronic check) option is available below the credit card choices listed in small type. Bank wire instructions: Wire to: TD Bank, N. A., 301 Railroad Street, St. Johnsbury, VT 05819, (802) Swift Code: NRTHUS33XXX ABA#: Credit to: St. Johnsbury Academy, 1000 Main Street, St. Johnsbury, VT Account Number: Memo: Student s Name Weekly Pocket Money Authorization (please select one): I LIMIT THE AMOUNT OF MY STUDENT S POCKET MONEY TO $ PER WEEK. Any fund requests above this amount will require written permission via to mmcginn@stjacademy.org. Any request for $ or more must be approved by either Mr. Ryan or Mr. Robillard. I ALLOW MY STUDENT TO WITHDRAW FUNDS ON A WEEKLY BASIS AS NEEDED WITH NO RESTRICTIONS. x STUDENT SIGNATURE x PARENT/GUARDIAN SIGNATURE FOR MORE INFORMATION, PLEASE MARCI MCGGIN AT MMCGINN@STJACADEMY.ORG BUSINESS OFFICE FORM

17 Main Street, St. Johnsbury, Vermont Telephone: (802) , Fax: (802) PLEASE RETURN THESE FORMS BY JULY 1. to or upload to your SNAP Health Portal page. Login information will be sent directly to parents and consultants. THANK YOU AND WE LOOK FORWARD TO SEEING YOU IN AUGUST!

18 CHARACTER INQUIRY COMMUNITY 1000 Main Street St. Johnsbury, Vermont Admissions (802) Fax (802)